Basic Information
| Provider Information | |||||||||
| NPI: | 1922091115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PROVOSTY | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | HURST | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 1527 | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283591527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388222 | ||||||||
| FaxNumber: | 9106710846 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 WEST 27TH STREET | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107388222 | ||||||||
| FaxNumber: | 9106710846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 07/20/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 000018135 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 18135 | NC | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 69325 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 8969325 | 05 | NC | MEDICAID |